An Iron Curtain Has Descended Upon Psychopharmacology

Imagine if a chemist told you offhandedly that the Russians had different chemical elements than we did.

Here in America, we use elements like lithium and silicon and bismuth. We have figured out lots of neat compounds we can make with these elements. We’ve also figured out useful technological applications. Lithium makes batteries. Silicon makes computer chips. Bismuth makes pretty gifs you can post on Tumblr.

The Russians don’t use any of these. They have their own Russian elements on their own Russian periodic table, with long Russian names you can’t pronounce. Apparently some of these also have useful technological applications. One of them is a room temperature superconductor. Another improves the efficiency of dirigibles by 500% for some reason.

No one in America seems remotely interested in any of these Russian elements. Many American chemists don’t even know they exist, even though each element has its own English-language Wikipedia page. When informed, they just say “Yeah, the Russians have lots of stuff,” and leave it at that.

American research teams pour millions of dollars into synthesizing novel elements in order to expand their periodic tables and the number of useful compounds they can make. If anyone suggests importing and studying some of the Russian elements, the chemists say “Huh, that never occurred to us, maybe someone else should do it,” and go back to spending millions of dollars synthesizing entirely novel atoms.

If a chemist told you this, you would think they were crazy. Science, you would say, is science everywhere. You can’t have one set of elements in Russia and another in the US, everyone would work together and compare notes. At the very least one side would have the common decency to at least steal from the other. No way anything like this could possibly go on.

But as far as I can tell this is exactly the state of modern psychopharmacology.

Consider anxiety. I would kill for a good anti-anxiety drug. Right now my choices are pretty limited. Benzodiazepines and barbituate work great but are addictive and dangerous. SSRIs work okay but need a month to take effect. Neurontin, Vistaril, and Buspar are safe, fast-acting, and totally ineffective. And Lyrica is expensive and off-label. As a result, a lot of my anxious patients tend to stay anxious.

Any textbook, database, or lecture you care to check on anti-anxiety medications will list the ones I just listed above plus a couple of others I’m forgetting.

But if you look the matter up on Wikipedia, you see all these weird names like mebicarum, afobazole, selank, bromantane, emoxypine, validolum, and picamilon. You can show these names to your psychiatrist and she will have no idea what you’re talking about, think you’re speaking nonsense syllables. You can show them to the professor of psychopharmacology at a major university and your chances are maybe like 50-50.

These are the Russian anti-anxiety drugs. They seem to have pretty good evidential support. Wikipedia’s bromantane article gives a bunch of studies of bromantane in the footnotes, including a randomized controlled trial in the forbiddingly named Zh Nevrol Psikhiatr Im S S Korsakova.

And look what else Wikipedia’s bromantane article says:

Study results suggest that the combination of psychostimulant and anxiolytic actions in the spectrum of psychotropic activity of bromantane is effective in treating asthenic disorders compared to placebo. It is considered novel having both stimulant and anti-anxiety properties.

Imagine reading about a Russian element on Wikipedia, and at the end there’s this paragraph saying “By the way, this element inverts gravity and has to be tied to the ground to prevent it from falling upwards”. An anxiolytic stimulant is really really cool. But somehow generations of American psychopharmacologists must have read about bromantane and thought “No, I don’t think I’ll pay any more attention to that.”

Given this situation, it’s perfectly reasonable for doctors not to prescribe them. Certainly I don’t plan to prescribe any Russian drugs when I get my own practice. Imagine if a patient gets liver failure on one – and remember that people are getting liver failure all the time for random reasons. The patient’s family decides to sue and I’m stuck defending my decision in court. “Yes, Your Honor, I admit I told the deceased to buy a medication no other psychiatrist in the state has ever heard of from a sketchy online Russian pharmacy. But in my defense, there was a study supporting its use in Zh Nevrol Psikhiatr Im S S Korsakova. Which I didn’t read, because I don’t speak Russian.”

Everyone follows their own incentives perfectly, and as a result the system as a whole does something insane. Classic multipolar trap.

Luckily, this hasn’t stopped a lively gray market trade in these chemicals, which I totally one hundred percent approve of. Noopept, for example, is a prescription drug in Russia but is sold over-the-counter by online suppliers here. You can even get some bromantane for two bucks a pill.

Don’t worry. I’m sure these people are on the level. How could a site with a background like that possibly be unreliable?

106 Responses to An Iron Curtain Has Descended Upon Psychopharmacology

Hey, question I’ve been meaning to ask: Where did you find the term “multipolar trap”, and what exactly does it mean?

Googling it gave me 168 results, and all the ones on the first page are from plasma physics journals (and of course completely incomprehensible to non-physicists). I’m inferring that the way you use it, it means something along the lines of “a Nash equilibrium that isn’t Pareto efficient”. But I don’t even have a guess at what the word “multipolar” refers to in that context.

Is it a neoreactionary thing? If so, is there a more standard game theory term for the same thing? (Or in any other field whose terminology I’d feel less embarrassed about using than the neoreactionaries’?)

While neither is exactly equivalent, tragedy of the commons and prisoner’s dilemma are similar often-used terms in game theory, and most educated people have some sense of what they mean. I generally use the phrase “prisoner’s-dilemma-type situation” or similar.

Consider this game: A million people simultaneously pick A or B. If you pick something different from the majority you get zero. If the majority picks A, everyone who picked A gets 1, whereas if the majority picks B everyone who picked B gets 2. There is an equilibrium where everyone picks A because everyone correctly expects the majority to pick A.

To be clear, I have a pretty good understanding of the actual game theory. What has got me confused is this one bit of rather opaque jargon; when terminology like that is used it’s usually because it has a particular meaning that would be hard to express without it, and which the audience can be expected to be familiar with. Scott has never directly explained why he calls it a “multipolar trap” so I doubt he made it up, but I can’t find it anywhere else on the internet so I’m mystified as to what context it’s from.

Since the examples I found of “multipolar trap” used this way are all from this blog, I’d guess Scott came up with the phrase. Your definition is correct.

It’s common to use “multipolar” to describe situations with many independent actors, and one of Scott’s main examples is The Two-Income Trap. So think tragedy of the commons and ignore the physicists talking about something completely different.

I just made up the term because I couldn’t think of an existing one that exactly captured what I meant. Yes, “multipolar” was probably influenced by Bostrom. I have heard other people use “coordination problem” but I don’t know enough formal game theory to know if that already has a formal meaning narrower than how I’m using it here so I didn’t want to risk it.

There’s a study I remember reading a few years ago that I now irritatingly can’t find, documenting the variation in countries in the rates at which they published negative scientific results. All countries seemed more inclined to publish positive results, but some countries pretty much only produced positive results. I wish I could remember if Russia was one of the especially troubling ones; if the bias for positive results is especially bad in Russia, that would obviously be a reason not to be too enthusiastic about the supposedly great results from their drugs.

You may be thinking of “Do Certain Countries Produce Only Positive Results? A Systematic Review of Controlled Trials” http://www.dcscience.net/Vickers_1998_Controlled-Clinical-Trials.pdf One problem with this is that it’s confined to results reported in English, so theoretically the by-country effects could be due to severe publication bias: only the drugs that turn in positive results are cool enough to be worth translating results into English and trying to get published in an English journal. This is important to know if you’re trying to read all the English articles about say Noopept (you’re getting heavily filtered results), but the original Russian literature on Noopept itself may or may not be terribly biased.

Yes, that’s the one I was thinking of, and now that I can check it again, Russia doesn’t look great, but you make a good point. It also looks like there aren’t very many studies included (perhaps another effect of it being confined to reports in English). So certainly not a conclusive indictment of all Russian medical research ever; just a possible reason to be slightly more skeptical and look a little more closely.

Given that we’re all supposed to spit and hiss when the name Lysenko is uttered, could one reason be that U.S. (and Western European, I have no idea) doctors and pharmacologists tend to go “Yeah…Russian research is a bit dodgy, let’s leave it at that”?

My understanding is that in Germany you can get prescriptions for a lot of what over in the U.S. are considered homeopathic treatments*, and I think we all know Scott’s position on homeopathy.

(*I’m going by what I’ve picked up from my Anthroposophist sister, who tends to buy a lot of stuff from German companies who run on these principles).

In Germany, homeopathic medicines are covered by state insurance with a prescription, and are about half a percent of total prescriptions.

In the U.S., numbers are more difficult to estimate because anything over the counter is usually not covered by insurance, so we don’t have insurance data. Homeopathy is more popular in Germany anyhow.

But to say “Oh, we don’t fall for that bunk here in the states” is premature. You can get insurance to cover doctor’s visits just fine even if they won’t cover over the counter pills, and this includes homeopaths if they have the right paperwork (they have to be a “licensed professional,” and even then only some insurance covers them). Total visits are about half a percent per person per year (going from wikipedia), about an eight the size of medical visits, and no doubt partially covered by medical insurance.

It probably doesn’t matter much, but I’m slightly unsure what you mean, because being considered ‘homeopathic’ in the U.S. does not at all mean the same as being homeopathic. In the U.S., it’s really just a marketing term, usually (IME) for things with active ingredients in measurable doses, and sometimes for things that actually work.

“Yes, Your Honor, I admit I told the deceased to buy a medication no other psychiatrist in the district has ever heard of from a sketchy online American pharmacy. But in my defense, there was a study supporting its use in The Annals of Pharmacotherapy. Which I didn’t read, because I don’t speak English.”

I’m mostly wondering if the bias goes both ways. I feel like American things have an air of legitimacy, even abroad. Do Russian doctors prescribe “American” medications in addition to their crazy Russian ones?

For drugs approved today, the standards are practically identical in America and Europe. The FDA process is more erratic, especially in duration, but it approves basically the same set of drugs as the EMA.

Which is not to deny your claim: many false things are widely acknowledged.

You’re probably right. I did some calculation and got ~2000 Russian speaking doctors in America and ~30000 English speaking doctors in Russia. According to my source Russia has 2x as many doctors per capita than America.

Medicine and Culture compares American, British, German, and French medicine– they get comparable results, on the average, while using not just different treatments, but different diagnoses. And they tend to focus on different organs.

Is there anyone systematically comparing medical practice in different countries to check for effectiveness?

So this is pretty clearly an abbreviation of “Journal of Neurology and Psychiatry named after S. S. Korsakov”, or in more idiomatic English, the “Korsakov Journal of Neurology and Psychiatry.”

And, yep, here is the (Russian) wikipedia page. The journal, which has been in publication since 1901, is named after Sergey Sergeyevich Korsakov (1854-1900), the author of a classic Russian psychiatry text book (1893) and one of the founders of experimental psychiatry in Russia.

EDIT: the cyrillic in the page name screws up my link. If you click on “найти упоминания,” the first link it finds is the correct page.

EDIT2: If you have actual articles from this or any other Russian publication you would like translated, I can do that for you.

If only there was as big of an online community devoted to translating medical studies as there is for subbing Japanese cartoons… Since that’s not going to happen, another reason software translation is a really huge deal if it ever gets out of its infancy.

The translation isn’t going to considered reliable unless there’s a name attached to it, and that name has a reasonable amount of prestige. And people might be reluctant to put their name on a translation that, if incorrect or read incorrectly, could be blamed for a death.

You’ve got to do the research right here in red-blooded American laboratories

Nope. The studies just have to be up to FDA standards. In particular, preregistration, but no geographical restriction. The only country with such restrictions is Japan, which is why they didn’t have the birth control pill until 1999. (And they probably don’t have geographic restrictions, but racial restrictions – Japanese in America or Brazil are OK.)

Buying drug rights is easy. The problem is probably that the Russians failed to apply for an American patent at the beginning, so the drug has been disclosed and is in the public domain. But it should be easy to modify and make a patentable me-too drug!

With that said, I’ve tried it dozens of times — both as “Ladasten” which I bought in Russia, and in raw form from tht.co — and I can’t say that it did much for me. At the recommended dose of 50-100mg, I didn’t notice any effects at all. At 200mg, a very vague sort of threshold effect. It’s certainly not the miracle drug the Russians made it out to be.

By the way, everything written about the Russian pharmacopeia also applies to the Italian pharmacopeia. It, too, has very strange drugs that are unused and little-known elsewhere. For example, the one-of-a-kind mineral stimulant rubidium chloride.

See also Stablon from the French. I am super glad I was able to get my hands on it. I think it’s especially unlikely to ever be blessed in America because its mechanism of action runs totally counter to the SSRI narrative, and there are multi-billion dollar interests behind the SSRIs.

This reminds me of the drug Algocalmin which was available in Romania over-the-counter until recently, when the Romanians got with the western EU standards and banned a bunch of things for no good reason. It was by far the best pain medication I’ve ever used. I’m non-responsive to opiates and so opiate-based painkillers are useless to me, and the non-opiate painkillers I get here in the US are too weak to help. Fortunately, I have a stash of Algocalmin that I brought over from Romania in my cubpoard.

Algocalmin(metamizole) can have some pretty nasty side-effects, so I wouldn’t call the banning “for no good reason”. Also, it’s interesting that you describe it as useful, since my experience with it has been “take one, and then take a goddamned ibuprofen/diclofenac 2h later when the algocalmin entirely failed to work”. I wonder what caused the difference; different sources of pain (I tried it for headaches, back pain, period pain, tooth aches,sports injuries and otitis) or maybe something else entirely.

As the Wikipedia article indicates, the incidence of serious side effects for metamizole is lower than the incidence of similar side effects for much more popular drugs, so I’m sticking with my judgement on this one.

In my family we generally use algocalmin for headaches. It’s the only thing I’ve seen that will straight up eliminate a migraine. But I suspect that we just have different idiosyncratic drug responses, since as I mentioned above opiates have no effect on me other than nausea–a condition which is unusual but not unheard-of.

Not just psychopharmacology. It keeps amazing me that drotaverine isn’t used in the West for every cramp between diaphragm and pelvic floor (seriously, the thing will calm down an 8-on-the-pain-scale period down to 0). Also, that when you use probiotics, it seems to be for all sorts of hippie reasons as opposed to fixing antibiotic digestive side-effects by taking it 2h later than the antibiotic, and that the antibiotic-side-effects-ameliorating use is rare enough that I could talk to US folk who needed to take antibiotics semi-regularly and who didn’t know that one extra pill could fix the damn diarrhea and nausea and loss of appetite.

…People don’t take probiotics for fixing antibiotic side effects? I am mildly surprised because my mother always gave us probiotics, although to be fair this might just have been that she’s into hippie shit and is aware that antibiotics kill off good bacteria too and wants to be on the safe side.

I’ve met at least 3 US folk with recurring medical issues that required antibiotics who had never even heard of the thing.
Also, I was never prescribed antibiotics without being at least told to take a probiotic too, nor I was ever given antibiotics in a hospital without a probiotic on the side.

Just speculating, but part of the explanation why Russian results and findings are not examined more carefully, to the extent that they are not, may be historical reasons. One way to put it would be to say that some parts of the psychiatric system of the Soviet Union served purposes it did not in the West.

If part of a guy’s job is/was to keep a perfectly sane and reasonable political dissenter locked up while using his expert status to convince everybody else that the dissenter is crazy and should never be allowed out of the hospital(/jail), I’m going to ask some questions before accepting his research findings. Stuff like this may play a role, and I’d actually be surprised if it didn’t.

I can see how weird US incentives keep these drugs from being available here, but there must be dozens of countries where there’s government run health care that gives incentives compatible with prescribing or at least studying these drugs. Is that what we see, or is there use pretty much limited to Russia or maybe the former USSR?

The incentives are exactly the same in every country. They all assume that drugs will be provided by private companies. They wait for the private companies to ask permission and provide the evidence for efficacy. I don’t know what India did before 1995, when they started respecting drug patents.

Also, the EU has a unified drug approval process, eliminating lots of independence. After the drug is declared safe and legal, the various countries make independent negotiations over price, and whether to advise their doctors to prescribe the drug.

Phenylpiracetam fucking rocks. Especially if you chase it down with a can of Red Bull. Tolerance to the best effects seems to build up very quickly for me, and the “Gotta go fast!” feeling turns from mildly euphoric to grating, so I only do it once a week or less.

This reminds me, are autovaccines(?) used in the West? In case I got the name wrong, it involves taking a biological sample from a patient with a chronic or recurring antibiotic-resistant infection, preparing a vaccine out of whatever’s in the sample and administering that in increasing and then decreasing doses to the patient for a few weeks.

I don’t know how well the patent excuse works here. Some of the drugs you list are well out of any possible patent protection, but several of them seem to be recent – ’90s and ’00s, going by the earliest year in the Wikipedia bibliographies. And if they did work, there are plenty of tricks drug companies could use to get patent protection: find some molecular tweak which is functionally identical, or simply patent an isomer. (Hey, it worked for Cephalon in extending modafinil’s patent protection as ‘Nuvigil’…) Plus the Russian research may not be enough to convince the FDA, but it at least does ‘derisk’ the investment somewhat since you can be reasonably sure your variant won’t explode in your face in the safety trials.

For that matter, what about other countries which have looser standards than the FDA?

As well, they don’t seem to be all that popular in the nootropics or Longecity communities; the only Russian drugs I’m really aware of are Noopept (which seems to be favored as a cheaper and much more compact substitute for piracetam) and phenibut (which apparently has nasty withdrawal which limits its use).

So the most parsimonious explanation seems to me that maybe the mentioned Russian drugs aren’t too effective. Running rigorous clinical trials is very difficult and it’s easy to fool oneself.

You don’t know what the drug companies know. They have a lot of money, after all. They could easily have hired some Russian-speakers to review the Russian literature for them, catalogued the informal reports from doctors and patients, or even run small pilot experiments – they aren’t especially obligated to report experiments where we can see them, that was the whole problem with Tamiflu, was it not? – and concluded that while the drugs may have passed muster in Russia, it wouldn’t fly elsewhere. The pharmacorps have a lot of money, and a lot of pressure to find new drugs; if there were a ‘there’ there, shouldn’t some of their delightful antics like patenting isomers work?

Hey Scott, another link for you (Did you see the one about benzo pollution improving fish life expectancy?). They just invented Fred Pohl’s virtual shrink (As seen in Gateway) and it seems to be be more popular with patients than the real thing: link.

The TLDR version would seem to be:
There are Russian drugs with extremely compelling psychopharmacological properties. For various interesting reasons these drugs are under-studied and unused by the medical establishment outside Russia. These drugs are available online — but, if you decide to use ’em yourself, caveat emptor. It’s implied that there is still some uncertainty about the properties of these drugs — which is certainly true.

It’s not just psychopharmacology. My allergy doc says there’s a drug used to treat asthma and allergies all over the world, but it’s not available in the US and because of the cost of FDA approval the manufacturer has publicly stated it will not seek approval in the USA.

What is the FDA going to do when the ability to “print” virtually any drug makes it obsolete? (I would assume psychiatrists would keep their jobs in advisory, but not necessarily prescriptive, roles. Oh how I would love if my psychiatrist just believed me when I said I can tell whether the drugs he prescribes are effective and useful.)

Suffice it to say that you’re right. As “atomic tweezers” seem unfeasible in the near future, and as 3D printers currently only work with very simple polymers, the “drug-printer” is a long way off. The closest we’re probably going to get in the near future is a automated reactor system — i.e. a system that automates chemical reactions and analytical testing — and this would probably require some professional skill to operate. (This sort of thing would probably start as an automated flow-reactor system that handles simple one-pot molecule synthesis and testing — but could feasibly get much more complex.)

Um, wrong. He was suggesting no such ting. While he WAS drawing a parallel, his preceding statements most certainly did NOT posit themselves as hypotheticals:
“The Russians don’t use any of these. They have their own Russian elements on their own Russian periodic table, with long Russian names you can’t pronounce. ”
“No one in America seems remotely interested in any of these Russian elements. Many American chemists don’t even know they exist, even though each element has its own English-language Wikipedia page.”

When he even gets passably close to doing as you claim, he very quickly makes clear this is NOT what he is doing:
“If a chemist told you this, you would think they were crazy. Science, you would say, is science everywhere. You can’t have one set of elements in Russia and another in the US, everyone would work together and compare notes.”

You should retract your current condescending ad hominem with higher priority than your previous unfounded nonsensical comment.
Note that is it not lost that you have failed to address the actual issue.

Sorry, but language simply does not work that way. The contract did NOT entail applying the descriptor to the entire first part of the piece, but simply to the fanciful conversation that served as an intro.

@Multi: So if someone has trouble modelling other people and understanding hypotheticals and sarcasm they are deserving of snark, but if someone is officially diagnosed as having trouble modelling other people and understanding hypotheticals and sarcasm then it’s not their fault and they should be treated kindly?

Everything from ‘Here in America, […]’ to ‘[…] entirely novel atoms.’ is supposed to be what the hypothetical chemist is saying to you, rather than something that Scott himself is asserting. Perhaps it should have been formatted in a blockquote, or something like that.

Simply writing something that is absurd and contrariety to reality does not inherently make something hypothetical, especially, as I have had to point out to others, in light of the rampant scientific illiteracy rampant in the media.

When I have my undergrads write on Hume, I’m always frustrated at how often they mistake Hume’s frequent hypotheticals for things Hume is asserting. I like to think that they’re hindered by Hume’s somewhat obsolete language, but sadly that’s surely not the whole story; it seems that some people just have enormous difficulty processing hypothetical scenarios.

Contrary to your condescending nonsense, I have no problem with hypotheticals, and I certainly had no problem “processing” Hume. What you conveniently fail to address is the fact that the determinant here is NOT the subject matter, it is the manner of writing. You can not merely say, “Of course it was hypothetical, it’s clearly nonsense, at odds with reality,” and leave it at that.
Note that nowhere have you addressed the fundamental issue: the language involved and precisely what constitutes a justified claim of hypotheticals. You could very easily quote where you think this is made clear in the piece, but failed to do so, again, simply hanging your hat on the false notion that, because it is absurd, it is clearly hypothetical, belied by the constant barrage of scientific illiteracy bombarding people on a daily basis. Your failure to do so is telling.

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